The Impact of Increased Access to Family Planning on Fertility and Health in Malawi

Improving access to family planning in Sub-Saharan Africa has the potential to help women and couples achieve their desired family size and avert unintended pregnancies and unwanted births. It may also have longer-term effects by improving women’s health, educational attainment, and socio-economic status. However, little is actually known about the effectiveness of family planning. In Malawi, Innovations for Poverty Action is working with researchers to measure how an increase in access to family planning—through information, transportation, and reimbursements for family planning services—impacts women’s fertility, health, and well-being.

Policy Issue

Despite a decline in birth rates and improvements to maternal health care, the total fertility rate and the number of unintended pregnancies and unwanted births remains high in Sub-Saharan Africa. Providing young African women with access to family planning may help them to effectively meet their desired family size, avert unintended pregnancies, and healthily time and space children over their reproductive lifetimes. It may also increase their capacity to attend and complete school and eventually obtain formal employment.1 However, young women in developing countries often lack access to basic information about contraception, side effects, and sexually transmitted infections, and among those women who report awareness, many tend to harbor misperceptions about contraceptives or possess only superficial information about these issues.2

To address these challenges, family planning programs have become increasingly common in developing countries. These programs either aim to increase demand for family planning by, for example, providing sexual and reproductive health behavior change programs or by informing women and couples about the benefits of family planning, or to increase the supply of services by improving access to contraceptives and family planning services. Yet little is known about the effectiveness of these approaches. This research aims to provide some of the first rigorous evidence on how family planning interventions affect women’s knowledge, contraceptive use, family planning choices, health, educational attainment, and well-being.

Context of the Evaluation

Although family planning services in Malawi are provided for free in public sector clinics, women often face several key barriers to access. These include (i) a lack of information on the benefits of family planning and healthy birth spacing, a lack of access to services, and a lack of method choice, (ii) long waiting times at public facilities, (iii) high transport costs to facilities, and (iv) a fear of contraceptive-related side effects. In addition, women who seek family planning services at private or commercial sector clinics often receive higher quality care but are required to pay out-of-pocket for receiving services and commodities. This study aims to determine the effect of a package that addresses these key barriers to access and leaves the question of the relative importance of each barrier to future research.

The study will be carried out in Lilongwe, the capital of Malawi. To be eligible for the study, a woman must be between the ages of 18-35, from Lilongwe, married, and either pregnant or have recently given birth in the past 6 months from when she was initially approached at baseline.

Details of the Intervention

Innovations for Poverty Action is working with researchers to measure the impact of increased access to family planning services on knowledge, fertility and health. Researchers will randomly assign 2,000 eligible women to either a treatment or comparison group.

A woman assigned to the treatment group will be offered a one-year long family planning package that includes:

Information: a family planning information package and four private counseling visits over the one year intervention period

Transportation: free transportation to a family planning clinic with low waiting times

Reimbursements: financial reimbursement for family planning services, which includes any out-of-pocket expenditures related to the receipt of family planning care, costs for treatments that are received at the family planning clinic (e.g. medications, contraceptive methods, consultation fees, exam fees, costs associated with the treatment of contraceptive-related side effects), and free over-the-phone consultations and referral services from a doctor in the event that she experiences contraindications or side effects related to her use of family planning.

Women assigned to the comparison group will receive a basic family planning information package that will contain information on where to access free family planning services in Lilongwe.

Researchers will measure the impact of the intervention one year and two years after the intervention has been implemented. After the intervention ends, they will measure knowledge of family planning and modern contraceptive use. Intermediate outcomes include fertility outcomes (parity, birth spacing), changes in desired fertility, unmet need for family planning, and outcomes associated with maternal and child health, including safe pregnancy, child birth height and weight, and nutritional status. Long-term outcomes include educational attainment (matriculation rates, years of schooling completed), labor market outcomes (employment status, female labor supply), and income earned for the women in the study.

Innovations for Poverty Action (IPA) is registered as a 501(c)(3) nonprofit organization. Contributions to IPA are tax-deductible to the extent permitted by law. IPA’s tax identification number is 06-1660068.